DAFTAR TAGIHAN KLAIM RAWAT JALAN PESERTA J

PUSKESMAS PRAGAAN
PONKESTREN MIFTAHUL HUDA LARANGAN PE
BULAN : MARET 2017

UMUR KODE
NO TANGGAL NO. KARTU / SPM NAMA PASIEN ALAMAT
L P ICD X
1 27/02/2017 1012860011 Ust. Kholik 30 PM. HUDA K038
2 27/02/2017 1711500004 KH. Abd. Aziz 59 PM. HUDA R05
3 27/02/2017 882 Ach. Mahrus 18 PM. HUDA R51
4 27/02/2017 2203100001 Moh Nur Aziz Abasi 7 PM. HUDA R509
5 28/02/2017 1106800005 Ghazali 34 PM. HUDA R05
6 28/02/2017 2810580001 K Rosidy 57 PM. HUDA M791
7 28/02/2017 823 Sulistiowati 19 PM. HUDA K297
8 28/02/2017 615 Syaiful Anwar 10 PM. HUDA R509
9 28/02/2017 10812830001 Amirul Mukminin 32 PM. HUDA I959
10 01/03/2017 10506751154 K Hosnan 45 PM. HUDA J069
11 01/03/2017 818 Luluk Rahmah 18 PM. HUDA J069
12 01/03/2017 10104110001 Moh Nur Ainil Y 6 Lar. Pereng R51
13 02/03/2017 830 Rama Nanda 17 PM. HUDA L309
14 02/03/2017 14610450002 Busani 70 Lar. Pereng I10
15 02/03/2017 16812650001 Misyani 50 PM. HUDA L309
16 02/03/2017 4909830004 Riskiyah 32 PM. HUDA K297
17 03/03/2017 1004650001 Umar 50 Lar. Pereng I10
18 03/03/2017 905 ST. Maisyaroh 17 PM. HUDA H669
19 04/03/2017 5307020001 Naili Asy Sarifah 14 PM. HUDA R509
20 04/03/2017 881 Zainur Rosi 19 PM. HUDA K529
21 04/03/2017 4309660002 Siyami 49 PM. HUDA I10
22 06/03/2017 5301470001 Amiriyeh 69 Lar. Pereng M791
23 06/03/2017 6802870004 Kholifatul M 25 PM. HUDA R05
24 06/03/2017 580760004 Niya 56 Lar. Pereng K529
25 06/03/2017 809 Ainur Rahmah 17 PM. HUDA G439
26 06/03/2017 822 Sufiatun Hasanah 17 PM. HUDA R51
27 07/03/2017 858 Sulhan Hamid 18 PM. HUDA I959
28 07/03/2017 870 Kholilur R 17 PM. HUDA J069
29 07/03/2017 5001580002 Maimunah 57 Lar. Pereng M791
30 07/03/2017 866 Sittiyah 18 PM. HUDA I959
31 08/03/2017 836 Moh Syafi'ie 18 PM. HUDA K297
32 08/03/2017 6404800001 Helmiyah 36 Lar. Pereng M791
33 09/03/2017 835 Rofiqoh 16 PM. HUDA R51
 UMUR KODE
NO TANGGAL NO. KARTU / SPM NAMA PASIEN ALAMAT
L P ICD X
34 09/03/2017 6804900005 Nur Fatma 25 Lar. Pereng K297
35 09/03/2017 885 Ahmad Fendi 16 PM. HUDA R51
36 10/03/2017 4804940002 Anisah 22 Lar. Pereng R05
37 10/03/2017 916 Moh Mansyur 19 PM. HUDA K297
38 11/03/2017 2911000002 Sanili 65 Lar. Pereng R05
39 11/03/2017 891 Fatimatuz Z 15 PM. HUDA R50.9
40 11/03/2017 5604870001 Rohanah 30 Lar. Pereng M791
41 13/03/2017 3529115604870001 Hozainah 57 PM. HUDA R05
42 13/03/2017 3529114406800005 Mutmainnah 45 PM. HUDA I10
43 13/03/2017 890 Faizatul Nabila 16 PM. HUDA K297
44 14/03/2017 634 Bahrul Ulum 9 PM. HUDA R50.9
45 14/03/2017 877 Rifatul Ummah 17 PM. HUDA R51
46 14/03/2017 801 Assari Latif 19 PM. HUDA R51
47 15/03/2017 606 Ahmad Farisi 10 PM. HUDA R50.9
48 15/03/2017 1910710001 Atba'ie 46 Lar. Pereng R05
49 15/03/2017 622 Rizqiyatun 12 PM. HUDA K297
50 15/03/2017 871 Miatus 19 PM. HUDA J069
51 16/03/2017 899 Moh Safiudin 17 PM. HUDA R51
52 16/03/2017 654 Saiful Wafa 9 PM. HUDA K529
53 16/03/2017 5501900008 Nur Tatik 17 Lar. Pereng R51
54 17/03/2017 624 Imamah 10 PM. HUDA R05
55 17/03/2017 648 Moh Sholehuddin 8 PM. HUDA K529
56 18/03/2017 5003630008 Muryana 54 Lar. Pereng A01
57 18/03/2017 1107530003 Atro 64 Lar. Pereng R05
58 18/03/2017 4607600008 Sami 57 Lar. Pereng M791
59 20/03/2017 5005500004 Jumaliyah 67 Lar. Pereng R50.9
60 20/03/2017 10509610004 Misru 56 Lar. Pereng M791
61 20/03/2017 1406530001 Ahmad 64 Lar. Pereng M791
62 20/03/2017 1706650004 Yusuf 52 Lar. Pereng M791
63 20/03/2017 4104610003 Marsuni 56 Lar. Pereng R05
64 20/03/2017 4110460002 Marsiya 61 Lar. Pereng M791
65 20/03/2017 906 Samsul Arifin 18 PM. HUDA R51
66 21/03/2017 5107680006 Mu'ani 49 Lar. Pereng M791
67 21/03/2017 887 Ainul Hadi 18 PM. HUDA K297
68 21/03/2017 817 Kusyoirul A 18 PM. HUDA K297
69 21/03/2017 642 Muflihatin 10 PM. HUDA R50.9
70 21/03/2017 60811530001 Sunami 60 Lar. Pereng M791
71 22/03/2017 48077000004 Ralima 46 Lar. Pereng M791
72 22/03/2017 4701600001 Siyena 58 Lar. Pereng M791
 UMUR KODE
NO TANGGAL NO. KARTU / SPM NAMA PASIEN ALAMAT
L P ICD X
73 22/03/2017 5406320004 Hose'i 57 Lar. Pereng R50.9
74 23/03/2017 10107110002 Zairotul Karomah 5 PM. HUDA R50.9
75 23/03/2017 620 Isnaniyah 10 PM. HUDA K529
76 23/03/2017 852 Ummiyati 17 PM. HUDA R51
77 23/03/2017 833 Sasi Rahma 17 PM. HUDA R51
78 24/03/2017 653 Sabrina Alfa Yusri 10 PM. HUDA A01
79 24/03/2017 10701820002 Mahtum 36 Lar. Pereng M791
80 24/03/2017 800 Ummiyah 18 PM. HUDA R51
81 24/03/2017 821 Moh Muafa 18 PM. HUDA K297
82 25/03/2017 845 Jusliyatun 18 PM. HUDA K297
83 25/03/2017 900 Nur Aini 18 PM. HUDA R50.9

TOTAL
IM RAWAT JALAN PESERTA JAMKESDA
KESMAS PRAGAAN
TAHUL HUDA LARANGAN PERENG
LAN : MARET 2017

DIAGNOSA KARCIS BIAYA TOTAL

(KODE ICD X) TINDAKAN MASUK TINDAKAN BIAYA
Sakit Gigi Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Batuk Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Chepalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
OBS. Febris Rp 7,500 Rp 7,500
Batuk Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Gastritis Injeksi Rp 7,500 Rp 1,000 Rp 8,500
OBS. Febris Rp 7,500 Rp 7,500
Hipotensi Rp 7,500 Rp 7,500
Ispa Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Ispa Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Chepalgia Rp 7,500 Rp 7,500
Darmatitis Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Hipertensi Rp 7,500 Rp 7,500
Darmatitis Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Gastritis Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Hipertensi Rp 7,500 Rp 7,500
Inpacted Cerumen Injeksi Rp 7,500 Rp 1,000 Rp 8,500
OBS. Febris Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Gea Rp 7,500 Rp 7,500
Hipertensi Rp 7,500 Rp 7,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 1,194,500
Batuk Injeksi Rp 7,500 Rp 1,000 Rp 1,186,000
Gea Rp 7,500 Rp 7,500
Migrane Rp 7,500 Rp 7,500
Chepalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Hipotensi Rp 7,500 Rp 7,500
Ispa Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Hipotensi Rp 7,500 Rp 7,500
Gastritis Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Chepalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
 DIAGNOSA KARCIS BIAYA TOTAL
(KODE ICD X) TINDAKAN MASUK TINDAKAN BIAYA
Gastritis Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Chepalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Batuk Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Gastritis Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Batuk Injeksi Rp 7,500 Rp 1,000 Rp 8,500
OBS. Febris Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Batuk Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Hipertensi Rp 7,500 Rp 7,500
Gastritis Injeksi Rp 7,500 Rp 1,000 Rp 8,500
OBS. Febris Rp 7,500 Rp 7,500
Chepalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Chepalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
OBS. Febris Rp 7,500 Rp 7,500
Batuk Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Gastritis Rp 7,500 Rp 7,500
Ispa Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Chepalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Gea Rp 7,500 Rp 7,500
Chepalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Batuk Rp 7,500 Rp 7,500
Gea Rp 7,500 Rp 7,500
Thypoid Fiver Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Batuk Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
OBS. Febris Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Batuk Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Chepalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Gastritis Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Gastritis Injeksi Rp 7,500 Rp 1,000 Rp 8,500
OBS. Febris Rp 7,500 Rp 7,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
 DIAGNOSA KARCIS BIAYA TOTAL
(KODE ICD X) TINDAKAN MASUK TINDAKAN BIAYA
OBS. Febris Injeksi Rp 7,500 Rp 1,000 Rp 8,500
OBS. Febris Rp 7,500 Rp 7,500
Gea Rp 7,500 Rp 7,500
Chepalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Chepalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Thypoid Fiver Rp 7,500 Rp 7,500
Myalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Chepalgia Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Gastritis Injeksi Rp 7,500 Rp 1,000 Rp 8,500
Gastritis Injeksi Rp 7,500 Rp 1,000 Rp 8,500
OBS. Febris Injeksi Rp 7,500 Rp 1,000 Rp 8,500

Rp 622,500 Rp 60,000 Rp 3,046,000

Pragaan, 25 Maret 2017

Kepala Puskesmas Pragaan

Hudi Kuswoyo, S. Kep. Ns

NIP. 19670609 198803 1 011
 DAFTAR TAGIHAN KLAIM RAWAT JALAN PESERTA JAMKESDA
UPT PUSKESMAS PRAGAAN
PONKESTREN MIFTAHUL HUDA LARANGAN PERENG
BULAN : MARET 2017

UMUR KODE DIAGNOSA ( KODE ICD X ) TINDAKAN KARCIS

NO TANGGAL NO. KARTU / SPM NAMA PASIEN ALAMAT
L P ICD X MASUK
35 9-Mar-17 885 Ahmad Fendi 16 PM. HUDA R51 Chepalgia Inj Rp 7,500
36 10-Mar-17 4804940002 Anisah 22 Lar. Pereng R05 Batuk Inj Rp 7,500
37 10-Mar-17 916 Moh Mansyur 19 PM. HUDA K29 Gastritis Inj Rp 7,500
38 11-Mar-17 291100002 Sanili 65 Lar. Pereng R05 Batuk Inj Rp 7,500
39 11-Mar-17 891 Fatimatuz Z 15 PM. HUDA R50.9 OBS. Febris Inj Rp 7,500
40 11-Mar-17 5604870001 Rohanah 30 Lar. Pereng M62.5 Myalgia Inj Rp 7,500
41 13-Mar-17 3529115604870001 Hozainah 57 PM. HUDA R05 Batuk Inj Rp 7,500
42 13-Mar-17 3529114406800005 Mutmainnah 45 PM. HUDA I10 Hipertensi Rp 7,500
43 13-Mar-17 890 Faizatul Nabila 16 PM. HUDA K29 Gastritis Inj Rp 7,500
44 14-Mar-17 634 Bahrul Ulum 9 PM. HUDA R50.9 OBS. Febris Rp 7,500
45 14-Mar-17 877 Rifatul Ummah 17 PM. HUDA R51 Chepalgia Inj Rp 7,500
46 14-Mar-17 801 Assari Latif 19 PM. HUDA R51 Chepalgia Inj Rp 7,500
47 15-Mar-17 606 Ahmad Farisi 10 PM. HUDA R50.9 OBS. Febris Rp 7,500
48 15-Mar-17 1910710001 Atba'ie 46 Lar. Pereng R05 Batuk Inj Rp 7,500
49 15-Mar-17 622 Rizqiyatun 12 PM. HUDA K29 Gastritis Rp 7,500
50 15-Mar-17 871 Miatus 19 PM. HUDA J06 Ispa Inj Rp 7,500
51 16-Mar-17 899 Moh Safiudin 17 PM. HUDA R51 Chepalgia Inj Rp 7,500
52 16-Mar-17 654 Saiful Wafa 9 PM. HUDA A09 Gea Rp 7,500
53 16-Mar-17 550190008 Nur Tatik 17 Lar. Pereng R51 Chepalgia Inj Rp 7,500
54 17-Mar-17 624 Imamah 10 PM. HUDA R05 Batuk Rp 7,500
55 17-Mar-17 648 Moh Sholehuddin 8 PM. HUDA A09 Gea Rp 7,500
56 18-Mar-17 5003630008 Muryana 54 Lar. Pereng A01 Thypoid Fiver Inj Rp 7,500
57 18-Mar-17 1107530003 Atro 64 Lar. Pereng R05 Batuk Inj Rp 7,500
58 18-Mar-17 460760008 Sami 57 Lar. Pereng M62.5 Myalgia Inj Rp 7,500
59 20-Mar-17 5005500004 Jumaliyah 67 Lar. Pereng R50.9 OBS. Febris Inj Rp 7,500
60 20-Mar-17 10509610004 Misru 56 Lar. Pereng M62.5 Myalgia Inj Rp 7,500
61 20-Mar-17 1406530001 Ahmad 64 Lar. Pereng M62.5 Myalgia Inj Rp 7,500
62 20-Mar-17 1706650004 Yusuf 52 Lar. Pereng M62.5 Myalgia Inj Rp 7,500
63 20-Mar-17 4104610003 Marsuni 56 Lar. Pereng R05 Batuk Inj Rp 7,500
64 20-Mar-17 4110460002 Marsiya 61 Lar. Pereng M62.5 Myalgia Inj Rp 7,500
65 20-Mar-17 906 Samsul Arifin 18 PM. HUDA R51 Chepalgia Inj Rp 7,500
66 21-Mar-17 5107680006 Mu'ani 49 Lar. Pereng M62.5 Myalgia Inj Rp 7,500
67 21-Mar-17 887 Ainul Hadi 18 PM. HUDA K29 Gastritis Inj Rp 7,500
68 21-Mar-17 817 Kusyoirul A 18 PM. HUDA K29 Gastritis Inj Rp 7,500
 BIAYA TOTAL
TINDAKAN BIAYA
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 7,500
Rp 1,000 Rp 8,500
Rp 7,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 7,500
Rp 1,000 Rp 8,500
Rp 7,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 7,500
Rp 1,000 Rp 8,500
Rp 7,500
Rp 7,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
 DAFTAR TAGIHAN KLAIM RAWAT JALAN PESERTA JAMKESDA
UPT PUSKESMAS PRAGAAN
PONKESTREN MIFTAHUL HUDA LARANGAN PERENG
BULAN : MARET 2017

UMUR KARCIS
NO TANGGAL NO. KARTU / SPM NAMA PASIEN ALAMAT KODE ICD X DIAGNOSA ( KODE ICD X ) TINDAKAN
L P MASUK
69 21-Mar-17 642 Muflihatin 10 PM. HUDA R50.9 OBS. Febris Rp 7,500
70 21-Mar-17 60811530001 Sunami 60 Lar. Pereng M62.5 Myalgia Inj Rp 7,500
71 22-Mar-17 480770004 Ralima 46 Lar. Pereng M62.5 Myalgia Inj Rp 7,500
72 22-Mar-17 470160001 Siyena 58 Lar. Pereng M62.5 Myalgia Inj Rp 7,500
73 22-Mar-17 5406320004 Hose'i 57 Lar. Pereng R50.9 OBS. Febris Inj Rp 7,500
74 23-Mar-17 10107110002 Zairotul Karomah 5 PM. HUDA R50.9 OBS. Febris Rp 7,500
75 23-Mar-17 620 Isnaniyah 10 PM. HUDA A09 Gea Rp 7,500
76 23-Mar-17 852 Ummiyati 17 PM. HUDA R51 Chepalgia Inj Rp 7,500
77 23-Mar-17 833 Sasi Rahma 17 PM. HUDA R51 Chepalgia Inj Rp 7,500
78 24-Mar-17 653 Sabrina Alfa Yusri 10 PM. HUDA A01 Thypoid Fiver Rp 7,500
79 24-Mar-17 10701820002 Mahtum 36 Lar. Pereng M62.5 Myalgia Inj Rp 7,500
80 24-Mar-17 800 Ummiyah 18 PM. HUDA R51 Chepalgia Inj Rp 7,500
81 24-Mar-17 821 Moh Muafa 18 PM. HUDA K29 Gastritis Inj Rp 7,500
82 25-Mar-17 845 Jusliyatun 18 PM. HUDA K29 Gastritis Inj Rp 7,500
83 25-Mar-17 900 Nur Aini 18 PM. HUDA R50.9 OBS. Febris Inj Rp 7,500

TOTAL Rp 622,500

Pragaan,
Kepala UPT Puskesmas Pragaan
 BIAYA TOTAL
TINDAKAN BIAYA
Rp 7,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 7,500
Rp 7,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 7,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500
Rp 1,000 Rp 8,500

Rp 60,000 Rp 682,500

s Pragaan